That number may have decreased nationwide in the past few years,
but California remains on the forefront of the problem,
accounting for 20 percent of the country’s homeless in 2014.

With the winter’s freezing temperatures and El Niño’s massive
rainstorms, what to do about the thousands living in our city
streets has been making headlines on both the East and
West coasts.

What policymakers and the general public need to recognize is
that the homeless are aging faster than the general population in
the U.S. This shift in the demographics has major implications
for how municipalities and health care providers deal with
homeless populations.

In the early 1990s, only 11 percent of the adult homeless
population was aged 50 and over. That percentage was up to 37 by
2003. Today half of America’s homeless are over 50.

In fact, people born in the second half of the baby boom
(1955-1964) have had an elevated risk of homelessness compared to
other age groups throughout their lives.

So how have people aged 50 and over become homeless? And what
happens to them and their health after they are homeless?

These are the questions my research team, funded by the National
Institute on Aging, has been asking 350 participants in a study
we’ve been conducting since July 2013 in Oakland, California.

Oakland’s older homeless

Our results have shown that a large proportion of the older
homeless population in Oakland first became homeless late in
life, and once they become homeless, their health declines
precipitously.

Oakland, like most places in the U.S., has a problem with housing
costs, particularly for older adults. In the United States, more
than 30 percent of renters and 23 percent of homeowners aged 50
and older spend more than half of their household income
on rent. This makes it hard to pay for food and medicine, and
puts them at high risk of becoming homeless.

California has the highest housing costs of any large state, and
they are rising faster than elsewhere. It is not surprising that
Oakland has a large homeless population.

The common perception of homelessness is that it is a problem
that afflicts only those with mental health and substance use
problems. But this description doesn’t describe the experience of
older adults, particularly those who first experienced
homelessness late in life.

For the most part, these are men and women who worked throughout
their lives in low-skill, low-wage jobs. They are also
disproportionately people of color: Oakland’s population is 28
percent African American, but 80 percent of our study
participants are.

The stories they have told us follow a similar pattern. One of
our participants spoke of the shock of losing his job after 27
years:

I had lost my job and just could not … find another one. So in
that 27 years, you know, I worked, you know, paid bills, and
pretty much tried to enjoy…the things that life gives you when
you go out and earn. But when I became homeless it was like a
little, it was like a little shock at the time…

Another described losing his housing after being evicted when his
wife had had a stroke and his daughter went back on her promise
to let them stay:

After we moved out of the place, turned in the keys and
everything we went over to her house and she said, “Y'all can’t
stay here.” And I said, “I got $9 in my pocket …at least let
your mother spend the night because we don’t have enough money
to get a motel room.” She said, “No.” So that was the
beginning.

Their lives became derailed by job loss, illness, a new
disability, the death of a loved one or an interaction with the
criminal justice system. Often, it was a combination of these
factors that led to homelessness.

The other half of the older homeless we surveyed had been
homeless on and off for years. Much of this time was spent
cycling through jails, prisons and hospitals.

For these people, life has been difficult from their childhood.

One participant described how abuse had caused him to flee his
family, beginning a lifetime of homelessness:

“Next time you, if you run away, I’ll beat you with a car chain
or I’m going to throw you out the window.” […] Then I looked
out the window and said – we lived on the 13th floor
– I said, “I ain’t playing with this man.” He went to
work, I had whatever I had on me, I was out the door.“

In many cases, participants' drug and alcohol abuse started
early, as did mental health problems.

File
photo of a homeless man making his way through the Brooklyn
bridge during low temperatures at Lower Manhattan in New
YorkThomson
Reuters

Shared health problems

All our study participants, whether newly homeless or homeless
for many years, faced challenges with their health once they lost
their home.

As research shows, homeless people in their 50’s and
60’s have similar or worse health problems than people in the
general population who are in their 70’s and 80’s.

There are many causes for this discrepancy. High rates of
smoking, alcohol and drug use; poor access to health care, poor
nutrition and high stress are just some of the factors that take
their toll.

People who are homeless also have a hard
time getting medical care. They may qualify for public
insurance, but they often don’t have the wherewithal to get to a
clinic or to contact a health provider. Others prioritize
obtaining food and shelter or don’t seek health care because of
shame around being homelessness or fear of how health care
providers will treat them.

When the homeless population was made up of a majority of younger
adults, health care providers focused on treating
substance use and mental health disorders, traumatic injuries and
infections, many of which could be treated with short-term care.

Now, with an older homeless population, health care providers
have the difficult task of managing chronic diseases like
diabetes and heart and lung disease.

People with chronic diseases need to make repeated visits to
their health care provider and adhere to complicated medication
regimens, specific diets and physical routines. None of these are
easy to stick to, but doing so becomes almost impossible for
people who are homeless.

Add to this high rates of cognitive impairment (problems with
memory, information processing and following directions),
functional impairment (the ability to manage daily tasks such as
dressing, bathing, toileting), mobility impairment (the ability
to walk), and deteriorating hearing and vision.

It is hardly surprising that only about one in five of our
participants were housed one year after we first met them.

Systemic change needed

The point our study highlights is that the systems set up in the
1980s were not designed to serve an aging population.

Carlo
Allegri/Reuters

Cognitive impairment, for example, makes it difficult to follow
through with instructions to come to appointments, fill out
complicated paperwork for disability benefits or housing
applications, or adhere to treatment regimens.

People with mobility impairments are not able to walk miles
between service providers, carrying their belongings with them.
People at high risk of falls are not well served by bunk beds or
by bathrooms in shared facilities that do not have grab bars and
slip-resistant floors.

Shelter and housing providers are grappling with the need to
provide clients with personal care assistants to enable them to
handle activities of daily living, like bathing and dressing.
They are reporting difficulty with clients whose cognitive
impairments make them unable to understand or follow rules.

Many Medicaid programs will cover the costs of personal care via
the Home and Community Based Services Program,
which is designed to keep Medicaid recipients living at home and
in the community instead of in expensive institutional care.

However, it is nearly impossible to arrange these services for
people living in temporary shelters or in the street.

While there are few data, our study suggests that many older
homeless adults will require nursing home placement, some of
which could have been avoided with housing and home-based
services.

Two years into our study, many of our participants have already
spent extended time in nursing facilities.

Death on the street

We have known for years that homeless people are likely to
die prematurely.

When the homeless population was younger, these deaths were
mostly attributable to substance use, violence and infectious
diseases.

Older homeless adults die at a rate four to five times what would
be expected in the general population but die from different
causes than do younger homeless adults. They die from the same
causes as do other people – heart disease and cancer – but they
do so 20 to 30 years earlier.

In the course of our study’s two years, for example, 14 of our
350 participants have died. Others are very ill and, we fear,
will die soon.

To put it bluntly, as a society, we face the specter of older
adults dying on the streets.

So, what is to be done?

Our argument is that there is no one-size-fits-all solution.

An individual who has spent 30 years rotating between
institutional care and the streets requires different services
than a 54-year-old man who has become homeless for the first time
after a period of extended unemployment.

To solve the problem of homelessness among older Americans, we
will have to find answers to two questions.

How do we adapt existing programs for homeless adults to meet the
needs of an aging population?

And possibly even more intractable but fundamental: how do we
stop older people from losing their homes?